7251 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGy APPLICATION & PERMIT 7251
ADDRESS �V` yV
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL '
Gr
.1 01H'a PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
• ON hSiPRONE
CONTRACTOR
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
N
Llc.No. 5'33 LIGHTING FIXTURES 5.00/1.00
CADNTRAcrors PPLIANCES-RESIDENTIAL 4.00
ONTRA
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LID.NO. SIGNS TRANS. 3.00
ADDRESS Ervc, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
APPOCANTS MOTORS SEE FEE SCH.
ADDRESS .J
SERVICE CHANGE , 10.00 �[
� o o LICENSED CON'I'kACTOkS DECLARATION
a u v . I hcmhy WHIT11 that I:un licensed under provislmhs of Chapter 9 ISSUANCE DATE
m G m (cennnenain6 with Suction 7000)al'Division 3 of IIIc Business and BLDG. ELECT. PLG. MECH.
F N z I'rofessions Cndc lull mhac is in full fu¢e d f-ct ❑ ❑ r❑
oi m o License CLas 7r Lin.Numbs
H w Date Contractor
Y s '-"� BUILDING PERMIT
rc ¢ ce u OWNER-BUILDER DECLARATION
A o a MISC.- REFER TO ORD INFORMATION
X 3 u r hereby al firm (hut I um exempt from the Con[raetors License VALUATION
rLL0 Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which reyuiresa permit toconstract,alter,
ce o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.N0. ELEC.
- O u requires the applicant for such permit to file a signed statement that +' TOTAL PERMIT TO
u w m Its is licensed pentium m the poi,smo a of the Contractor's License
Fzi Law(Chapter 9(commencing with Section 7000)of Division3 ofthe Ld
a Business and POFcssions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
t ¢ F o the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
a gLTER-DRAIN& VENT-WATER (EA.) 4.00
_ by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(5500).):
❑ h as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP.- RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONO. 4.00
Code:The Contractor's License Law does not apply to an owner of
' property who builds or improves thereun,and who doe,such work FIXTURES-PER TRAP 4.00 s0.FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve-
II Rents ore not intended or offered for sale.if,however,the building GAS-EA.SYSTEM-I INC.40UTL ETI 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am-
RES IND CON PB Omer
{ prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 El El ❑ ❑ ❑
I ❑ I,as owner of the property,am exclusively contracting with
I liamsed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 r ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
f contends for such projects with a conlmctots)licensed pursuant to _
me Contractor's License Law. - SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec. .B.&P.C.for this WATER HEATER W/VENT 4.00 L;e
reason
Owner Date WATER SYSTEM 4.00 4,4 1 ACC.DATE ACC.FILE NO.
I
WORKERS'COMPI!NSA'IION DECLARATION WATER TREATING EQUIP. 4.00
I hereby atl'ino that I have a c,riiFwte of conscnl to sell-insure, ZONING
or a cerlificate of Worker,'Com pcnsution In.mance,or a certified
ENG.SITE NO.
h copy thcreol'(See 3800,Latif.).
�i Policy Nu. Company
U ❑ CertilicJ copy is hereby furnished. _ FIRESPRINK ENERGY T-24
t Z 2 ❑ Certified copy is fled with the city inspection division, MISC.- REFER TO ORD.
1 O Applicant Y❑ N❑ Y ❑ N❑
y
CER'I'1I§CA'fl>OP IiX1iM1'TION FROM WORKERS' PERMIT ISSUANCE 6.00 - FLOOD ZONE A.L.U.C.
I LU > COMI'IiNSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
h1 ❑ ❑ ❑ ❑
O ("('his section need not he completed it the permit is for one TOTAL O!o V N V N
Z hundred dollars(S 100)or less.)
U O I certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any'person in any manneroa as to
U become object ler the Workers'CIu n LCalifornla-_ i
1 U a Date I Applicant 7- w �� ALTER OR ADD TO MECH. 4.00 BUILDING
- N NOI ICF 'I O APPLICANT: If,after making this CertlGc.,sL 0f Ex-
r Z emptier,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
- provisions of the Labor Codc, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
C'ONSI'RUCPION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby allirm Her [here is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance 0f the work for which this permit is issued(Sec. HEATING UNIT IT 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ C.),
Lenders N,ancH EATING UNIT(OV ER 100,000 B.T.U. 7.50
Lender's Address )
ess ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 PLUMBING
information is correct. I agree to comply with all city and county 0
•„r ordinances and stain laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 S-6/
hereby autmriz representatives of this city to enter upon the BOILER-COMP (Over 10000OBTU1SEE FEESCH. MECHANICAL
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenseswhich PERMIT ISSUANCE 3.00 CONST.TAX
miry in any way accrue against said City in consequence of the
gmyl{[h�l�t1-111 perlhm[>/� MECH.CONT. LIG NO. MECH.
not s i TOTAL TOTAL
Sgnat a pplicant ontractor Date
INSPECTOR COPY